Medilodge Of Sault Ste. Marie
Inspection history, citations, penalties and survey trends for this long-term care facility in Sault Ste. Marie, Michigan.
- Location
- 1011 Meridian Road, Sault Ste. Marie, Michigan 49783
- CMS Provider Number
- 235292
- Inspections on file
- 30
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Medilodge Of Sault Ste. Marie during CMS and state inspections, most recent first.
Surveyors found systemic understaffing that led to multiple residents not receiving timely incontinence care, bathing, repositioning, restorative services, or assistance with preferred wake times and transfers. A resident was repeatedly observed lying in urine and feces while calling out for help without prompt staff response. Another cognitively intact resident with a leg fracture reported unanswered call lights for extended periods, missed or delayed meals, and having to phone the facility for help, with the call answered by other residents instead of staff. Additional residents described being left wet and soiled for hours, not receiving scheduled showers, and experiencing severe pain when left in bed far beyond their preferred wake times. Staff interviews confirmed frequent operation with only a few CNAs for dozens of residents, lack of coverage for call-ins, and an absence of restorative services on weekends or when the restorative aide was off. Facility records, complaints, and Resident Council minutes documented ongoing concerns about low staffing, long call light waits, and chronically late meal service, especially on weekends and nights.
A resident with dementia, severe cognitive impairment, and urinary/bowel incontinence was repeatedly left in urine- and feces-soiled bedding despite activating the call light and verbally calling for help. Staff confirmed the call light was functioning, but after a male staff member turned it off and said he would get an aide, no one returned for an extended period while the resident remained cold, wet, shivering, and visibly soiled, with feces on bedding, mattress, and hands. An LPN briefly entered and exited without providing care, and a CNA could not recall when the resident last received care. The resident expressed anger, sadness, and a desire to leave due to not being cared for, consistent with the facility’s own definition of neglect.
Surveyors identified systemic infection control failures, including delayed initiation of Enhanced Barrier Precautions (EBP) for multiple residents with surgical wounds, pressure injuries, dialysis catheters, and indwelling urinary catheters, despite clear criteria in facility policy. Several residents on EBP did not have appropriate door signage or PPE carts in place, and staff such as an OT and an LPN provided direct care without required gowns. Medication and treatment carts were observed with open drinks, food crumbs, stains, dust, and debris, even though they housed wound care supplies. A CNA assisted three residents with feeding, moving between them and handling utensils, cups, and trays without performing hand hygiene. Food carts on two halls contained both unserved and soiled meal trays together, with dirty trays placed above or next to clean ones, contrary to food separation standards. The infection preventionist acknowledged that EBP initiation was often missed when she was absent and confirmed that the existing infection control policies were the most current versions, which required an annual review of the infection prevention and control program.
Surveyors found that the facility did not adequately maintain cleanliness and repair in multiple resident and common areas. At the main entrance, a wet floor sign and a container partially filled with water were placed under a skylight with visible water damage, and the Maintenance Director reported he had been told not to continue roof repairs due to warranty concerns. On one resident hall, a shared bathroom had a soiled floor and chipped, worn paint on the door and frame, while several resident rooms had damaged walls with missing paint exposing bare plaster, additional areas of missing paint, and cove base molding peeling away from the wall.
Surveyors found that meals were routinely delivered on trays with disposable plastic utensils instead of standard silverware, with some trays including only plastic cutlery and others mixing regular forks and spoons with plastic knives. Staff reported that trays often did not return in time to be washed for the next meal, believed residents were keeping silverware, and acknowledged knowing plastic utensils were being used without ordering more silverware. Multiple residents in a confidential group interview voiced frustration that plastic cutlery, including knives that would not cut meat, was being used at mealtimes, and a prior complaint to the State Agency alleged meals were not adequately served due to limited utensils, despite a facility policy stating residents have the right to a dignified existence.
The facility failed to provide palatable meals at safe and appetizing temperatures, as multiple residents reported that food and coffee were often cold or lukewarm and that trays sat in serving windows or delivery carts for extended periods due to staffing issues. Resident council minutes over several months documented ongoing, unresolved complaints about cold room trays, lukewarm dining room meals, and pre-poured coffee served at inadequate temperatures. A cognitively intact resident with lower leg fractures, dependent on staff for some ADLs and blood glucose checks, reported that breakfast and lunch were frequently cold because staff were late checking blood sugar. During a lunch observation, surveyors measured beverages at 59°F and hot food items at 106–107°F on a tray from a food cart, which did not meet FDA Food Code hot and cold holding standards, despite a facility policy requiring prompt meal service and accommodation of preferences.
Surveyors found that the facility repeatedly failed to follow documented food preferences and standing diet orders, and did not consistently offer substitutes when meals were incorrect or uneaten. Multiple residents received the wrong type or amount of juice, were served disliked or non‑listed vegetables without alternatives, or were given different sandwiches and entrées than those specified on their tray cards or handwritten menus (such as receiving hamburgers instead of requested hot dogs). Some residents who required extra sauces or gravy received dry ground or chopped meats, and one resident reported not eating the meal because it was too dry. Trays were removed from at least two residents, including one with malnutrition and severe cognitive impairment, without offering alternative food or beverages. Residents also reported that the kitchen frequently ran out of items listed on the Always Available menu (e.g., ice cream, yogurt, pudding, cookies, hamburgers, hot dogs), and one resident on a gluten‑free diet stated they were served salad for two meals a day, five days a week and wanted something other than salad. Resident council minutes documented ongoing, unresolved complaints about receiving disliked foods and the kitchen running out of preferred items.
A resident with a leg fracture, who was cognitively intact, reported that four hydrocodone/acetaminophen tablets she had brought from home in her purse were missing when she attempted to use them for pain, and the admission inventory did not list any medications. The DON acknowledged uncertainty about whether nurses routinely asked about or inventoried medications at admission. Around the same time, staff described an RN as appearing under the influence, not passing meds as expected, wobbling, falling asleep at the med cart, and prompting concerns that residents were not receiving correct pain meds. The administrator later found an empty hydrocodone bottle and other medications in the resident’s purse, and a room search revealed marijuana gummies, cigarettes, and a lighter, demonstrating a failure to safeguard and properly account for the resident’s personal narcotic medication.
A resident with a left leg fracture, cognitively intact per BIMS, reported that a night shift nurse had taken four hydrocodone/acetaminophen tablets the resident brought from home and kept in a purse. The concern was reported to facility staff and discussed by the NHA and a nurse with the resident, but the NHA acknowledged the allegation was not promptly reported to the SA. The SA report was submitted later than required, despite facility policy mandating that such violations be reported to the administrator, SA, APS, and other required agencies within specified timeframes, including within 24 hours for events not involving abuse or serious bodily injury.
A cognitively intact resident with a left leg fracture reported that a night shift nurse took four hydrocodone/acetaminophen tablets the resident stated were brought from the hospital and kept in a purse, and this concern was documented by the DON. Despite a policy requiring immediate and thorough investigation of alleged abuse, exploitation, and misappropriation, the facility did not conduct or document a complete investigation: 16 potentially involved or knowledgeable staff were not interviewed, and the DON could not initially provide investigation documentation. The DON also indicated that only clothing was routinely inventoried at admission and was unsure whether nurses asked about medications, showing that resident medications were not consistently inventoried or accounted for as required by facility policy.
A resident at risk for pressure ulcers who required assistance with turning and repositioning was observed lying on her back for an extended period without staff entering to assist or encourage repositioning. Another cognitively intact resident with diabetes and a hip fracture was noted to have long facial hair and reported not having been shaved in a long time, while a CNA acknowledged that residents were supposed to be shaved on admission, on shower days, or upon request, but that residents were sometimes neglected due to staffing issues. A third cognitively intact resident with fractures, diabetes, and chronic kidney disease requiring dialysis reported being left wet and soiled in urine and feces for over two hours and stated she had not received a shower during her two-week stay, despite documented preferences for showers and dependence on staff for bathing and toileting; records and CNA statements confirmed multiple missed showers and lack of bathing interventions in her ADL care plan.
The facility failed to complete a timely admission assessment and to initiate bowel protocols according to orders and residents’ needs. A cognitively intact resident admitted with a recent leg fracture reported that on arrival staff briefly entered and left without explanation, no vital signs or head-to-toe assessment were done, dinner was delayed, and repeated call lights went unanswered, leading the resident to phone the facility, where other residents answered before staff responded. Another resident with multiple comorbidities, including a sacral pressure ulcer and constipation, reported no bowel movement for several days despite repeated alerts by the resident and family; documentation showed no bowel movement since admission, frequent opioid use, delayed administration of PRN Milk of Magnesia beyond three days without escalation to ordered suppository or enema, and late initiation of scheduled laxative and stool softener. A third resident with neurologic disease and mild cognitive impairment experienced ongoing nausea, declined meals, and had no bowel movement documented for several days, yet no bowel assessment or use of ordered PRN bowel medications was recorded, and the DON acknowledged inconsistent use of bowel elimination reports and the absence of a bowel protocol policy.
The facility failed to implement required fall-prevention interventions for a resident with moderate cognitive impairment and a history of seizure disorder and fracture, whose care plan called for fall mats on both sides of the bed. Surveyors observed the bed in a high position with the mats folded behind a chair in another room, while a CNA and an RN confirmed the mats were supposed to be in place but were not set up as a CNA task. The facility also failed to ensure safe smoking practices for another resident with mobility limitations and moderate cognitive impairment, who repeatedly went outside in very cold, snowy conditions to smoke just outside the door, retained his own cigarettes and lighter, and inconsistently used a sign-out book, despite a written non-smoking campus policy prohibiting smoking on facility property and resident possession of smoking materials.
Two residents at high risk for skin breakdown, both with existing wounds and significant mobility and incontinence issues, did not receive timely and consistent pressure ulcer prevention and treatment interventions. One resident’s buttock skin progressed from moisture-associated skin damage to unstageable necrotic pressure ulcers requiring hospitalization and surgical debridement, while documentation showed delayed ordering and placement of a low air loss mattress despite ongoing deterioration. Another resident admitted with multiple pressure injuries and requiring maximal assistance for mobility was repeatedly observed in bed without a low air loss mattress, without effective offloading of the buttocks or heels, and with heel protection boots left unused on the nightstand. Facility records and staff interviews showed that identified risk factors and care plan recommendations for pressure redistribution and offloading were not consistently translated into physician orders and implemented interventions, contrary to the facility’s own pressure injury prevention policy.
A resident with a recent lumbar fusion and multiple comorbidities did not receive timely dressing changes or proper documentation for a post-operative back wound. Nursing staff failed to notify the provider of wound dehiscence and changes in the wound's condition, resulting in the resident developing a surgical site infection that required hospital admission and surgical intervention.
A resident reported visible mold in a community shower room, which was confirmed by direct observation. Staff interviews revealed that although daily and monthly cleaning routines were in place, the mold was not identified or reported by housekeeping, and maintenance was not notified. Facility leadership acknowledged the issue and the need for repairs.
A resident with moderate cognitive impairment engaged in inappropriate touching of other residents, including kissing and touching on the thigh and breast. Staff witnessed and reported these incidents, but no evaluation was conducted to determine the affected residents' capacity to consent. The facility's policy on abuse prevention was not effectively implemented, leading to repeated incidents.
A facility failed to thoroughly investigate allegations of sexual abuse involving a resident who had inappropriate interactions with other residents. The investigation lacked detailed documentation, including specific dates, times, and locations of incidents, and witness statements were inconsistent or missing. The Nursing Home Administrator acknowledged these deficiencies, which posed a potential risk for further exposure to abuse for other residents.
The facility failed to maintain adequate staffing levels, as evidenced by low staffing ratings and interviews with residents and staff. On multiple occasions, the number of CNAs scheduled was below the required levels, leading to unmet resident needs. Residents and family members reported delayed responses to call lights and inadequate care, with some residents left in soiled clothing or experiencing distress due to long wait times.
The facility failed to ensure safe and sanitary conditions for six residents with personal refrigerators in their rooms. Observations revealed that these refrigerators lacked thermometers and temperature logs, with internal temperatures ranging from 37 F to 54 F. The facility's policy for refrigerator use, which included maintenance inspections and temperature monitoring, was not followed, as confirmed by the housekeeping supervisor.
The facility failed to provide proper respiratory care for four residents, including incorrect oxygen flow rates, lack of physician orders for CPAP use, and improper storage of equipment. One resident had an outdated nasal cannula and incorrect oxygen flow, while two others had CPAP machines without orders or proper documentation. Another resident's oxygen bubbler was empty, causing discomfort, with no physician orders for oxygen use. Facility policies requiring physician orders and proper equipment management were not followed.
The facility failed to secure medications properly, with an unlocked treatment cart containing topical creams and wound care supplies, and a resident's Nystatin cream left in her bathroom despite her not wishing to self-administer medications. Additionally, the D-hall medication cart had unlabeled crushed medications, loose pills, and a nurse's beverage stored improperly, violating the facility's medication storage policy.
The facility failed to update care plans for four residents, resulting in plans that did not reflect their needs. One resident's care plan was unclear to staff after an altercation, another's lacked updates after hospitalizations for catheter issues, a third's did not address contracture management, and a fourth's was not updated after an altercation. The DON and RN acknowledged these oversights.
A resident with moderate cognitive impairment experienced verbal abuse from a CNA, who used inappropriate language after the resident had an accident. The incident was reported by other staff members who overheard the altercation, and the resident expressed feeling bad about the situation. The facility's policy on abuse prevention was not followed, leading to this deficiency.
A resident with severe cognitive impairment and contractures did not receive appropriate treatment to maintain or improve range of motion. Despite being on the facility's case load for contracture treatment until September, no interventions were in place to prevent further decline. Staff acknowledged the need for restorative therapy, but the program had not been implemented.
A facility failed to provide adequate social services for a resident with severe cognitive impairment after an altercation with another resident. Despite the incident being documented, the resident's care plan was not updated, and there was no evidence of follow-up by social services. Interviews revealed that expected actions, such as care plan updates and documentation, were not completed, indicating a deficiency in providing necessary social services.
A facility failed to maintain a medication error rate below 5%, resulting in an 11.54% error rate. A resident with diabetes and hypertension received insulin injections improperly, leading to leakage, and was given carvedilol despite low blood pressure. The RN was unaware of the blood pressure parameters and the facility's policy on medication administration was not followed.
The facility failed to implement effective infection control practices and proper PPE use for residents with COVID-19. Observations showed open doors for rooms requiring airborne precautions, unclear signage, and improper PPE handling. Staff were not adequately informed about isolation precautions, and PPE was worn from resident rooms into hallways, violating facility policy and CDC guidelines.
The facility did not post the contact information for the Office of the State Long-Term Care Ombudsman, affecting all 74 residents. During a group meeting, residents expressed unfamiliarity with the Ombudsman and lacked knowledge on how to contact the office. Observations confirmed the absence of posted information, and interviews with facility administrators revealed no existing policy for such postings.
The facility failed to accurately post the actual hours worked by nursing staff, including RNs, LPNs, and CNAs, on their daily staffing postings. The postings did not reflect adjustments for changes, such as a nurse calling in sick, leading to incomplete staffing information being available to residents and visitors. This deficiency potentially affected all 74 residents.
Two residents eloped from the facility undetected, despite wearing Wanderguard bracelets. The alarm system failed to alert staff due to a visitor holding the door open, and staff were desensitized to frequent alarm activations. The incident was not accurately reported initially, and staff failed to respond appropriately, leading to the residents being found on a roadway.
The facility failed to prevent two incidents of resident-to-resident sexual abuse. In one case, a resident with PTSD was inappropriately touched by another resident with dementia in the dining room, despite a care plan prohibiting the latter's presence there. In another case, a CNA found a resident with exposed genitalia and another resident nearby, but the incident was not documented. The facility's policies on abuse prevention and trauma-informed care were not effectively implemented, and communication about residents' behavioral histories was inadequate.
The facility failed to report an employee's criminal conviction for brandishing a firearm to the State Agency, potentially jeopardizing the safety of 69 residents. Administration was unaware of the conviction, believing charges were dropped, despite the employee claiming previous notification. Facility policies require reporting such convictions to authorities.
The facility failed to provide adequate staffing, resulting in unmet care needs and potential safety issues for residents. On a night shift, only one LPN and three CNAs were available for 80 residents, contrary to the staffing plan. Residents reported delays in care, including hygiene and wound treatments, and a resident experienced a 14-day delay in surgical staple removal due to low staffing.
A facility failed to report a potential sexual abuse incident involving two residents, as observed by a CNA. The incident was not documented, and the LPN involved cited a busy schedule as the reason. Additionally, the facility inaccurately reported an elopement incident, stating residents were found on the sidewalk when they were actually in the roadway. The door alarm was silenced without checking for residents, and the Regional Director of Operations admitted to not accurately reporting the incident. Facility policies on incident reporting and abuse prevention were not followed.
The facility failed to investigate an allegation of potential sexual abuse between two residents. A CNA observed a resident with severe cognitive impairment standing beside another resident with exposed genitalia. The incident was reported to an LPN and the Regional Director of Clinical Services, but no documentation was made. The LPN cited a busy workload as the reason for not documenting, and the Regional Director did not follow up. The Nursing Home Administrator stated that such allegations should be reported and investigated immediately, which was not done.
The facility failed to provide timely meal service according to resident preferences, resulting in frustration and hunger among residents. Meals were consistently delayed, with some residents receiving lunch over an hour after the scheduled time. The Registered Dietitian confirmed the main dining room was always served first, with other halls rotated, but no formal policy was in place.
The facility failed to notify physicians of medication unavailability, delaying antibiotics for two residents. One resident with a UTI did not receive Nitrofurantoin on time, and another with enterocolitis did not receive Vancomycin as scheduled. The facility's policy required immediate action and physician notification, which was not followed.
A resident with severe cognitive impairment and a high fall risk experienced multiple falls shortly after admission, culminating in a significant head injury and hospitalization for a subdural hematoma. The incidents occurred due to gaps in supervision, including staff unavailability during critical times. The facility's fall prevention policies were not effectively implemented, as evidenced by the lack of direct supervision and monitoring during the fall incidents.
The facility failed to properly don PPE for residents in Enhanced Barrier Precaution rooms and did not maintain an effective TB testing program. Staff were observed not wearing required PPE during direct care, and several residents did not receive necessary TB tests upon admission, with discrepancies in documentation. These deficiencies indicate lapses in infection control practices.
The facility failed to obtain a physician order for an indwelling catheter for a resident who returned from the hospital with the device. Staff were unaware of the necessity for such an order, and multiple instances of catheter issues were observed without a corresponding physician order. Interviews confirmed that a physician's order is required, but none was found in the resident's records.
Systemic Understaffing Leading to Unmet ADL Needs, Delayed Call Responses, and Late Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs for ADLs, timely incontinence care, repositioning, restorative services, and prompt response to call lights, as well as to provide timely, dignified, and palatable meal service. Staff, including an LPN and multiple CNAs, reported that there were never enough CNAs, that they worked short all the time, and that management did not replace staff who called in. Residents repeatedly reported fear, frustration, and distress related to long call light response times, lack of assistance, and inadequate staffing. Facility records, including Payroll Based Journal data, complaint logs, Quality Assistance Forms, and Resident Council minutes, documented ongoing concerns about low staffing, delayed call light response, and late meals, particularly on weekends and nights. One resident was repeatedly observed lying in bed in urine and feces with feces on bedding, mattress, and hands, shivering and yelling for help over extended periods on multiple days, without timely staff response. Another resident, cognitively intact and recently admitted with a leg fracture, documented in a notebook and reported that call lights went unanswered for long periods, that no vital signs or assessments were done at admission, that meals were missed or significantly delayed, and that a call to the facility was answered by other residents rather than staff. This resident described waiting approximately 55 minutes for assistance to the bathroom after activating a call light and reported not receiving needed ice for a surgical wound. Additional residents described being left wet and soiled in urine and feces for over two hours, not receiving showers for weeks despite documented shower schedules and preferences, and not being assisted out of bed as desired. One resident with spastic quadriplegic cerebral palsy, intact cognition, and total dependence for transfers reported not being gotten out of bed by the preferred wake time, experiencing significant pain when left in bed for extended periods, and having submitted multiple written grievances about staffing and delayed care. Another resident with quadriplegia and anoxic brain damage, totally dependent for mobility, reported not receiving restorative therapy or consistent splint use, while CNAs stated they did not perform restorative tasks due to lack of time and that only a restorative aide, unavailable on weekends and currently off work, handled such care. Observations and interviews also showed residents waiting in soiled briefs until after meals for morning care, meal trays piling up due to insufficient staff to pass them, and activities being rescheduled because dependent residents were not assisted out of bed in time to attend. Facility documentation showed that the facility assessment set a maximum census of 78 residents, yet census data revealed 90 days in which the census exceeded this number, reaching up to 87 residents, with a high proportion of admissions and discharges occurring Friday through Sunday. Night shift schedules for multiple weekend days showed only 3.5 to 4 CNAs on duty for 73–82 residents. Complaints and Quality Assistance Forms from residents and families described residents sitting in stool and urine for hours, long call light waits (often 45 minutes to over an hour), residents not being toileted or put to bed when requested, residents not being gotten out of bed for days, and staff telling residents that there were not enough staff to honor their preferences for getting in and out of bed. Responses on these forms frequently cited staff education or asserted that staffing was adequate, and several forms lacked documented resolution, while concerns about staffing, call light response, and late meals recurred month after month in Resident Council minutes.
Failure to Provide Timely Incontinence Care and Response to Call Light
Penalty
Summary
The facility failed to provide routine incontinence care and timely assistance to a resident with severe cognitive impairment, frequent urinary incontinence, and occasional bowel incontinence. On multiple observations, a strong odor of urine and feces was noted from the hallway outside the resident’s room. The resident was found lying in bed in a fetal position with the bottom sheet pulled off the mattress and gathered around her, and a top sheet draped over her torso and lower body. Feces was observed on the pillowcase, sheets, fitted sheet, and mattress, as well as on the resident’s hands and under her fingernails. The resident repeatedly stated she was cold, soaking wet, and needed to be cleaned up, and reported she had not gotten out of bed that day. The resident activated her call light, which was confirmed to be functioning as indicated by the illuminated light above the door. An unidentified male staff member entered the room, was informed by the resident of her need for cleaning and warmth, turned off the call light, stated he would try to get an aide, and then left without providing care. No staff entered the room for at least 29 minutes after the call light was activated, during which time the resident continued to call out for help. Later observations showed the resident still soiled and shivering, yelling for help with no staff visible in the hallway. An LPN/Unit Manager briefly entered and exited the room, verbally noting the resident wanted to get up, but did not return to assist. A CNA could not state when the resident last received care. The resident expressed anger, frustration, helplessness, sadness, and a desire to leave the facility due to not being cared for. The facility’s abuse, neglect, and exploitation policy defined neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress.
Systemic Infection Control Failures Including Delayed EBP, Poor PPE Use, and Unsanitary Practices
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control program, including delayed implementation of Enhanced Barrier Precautions (EBP), improper use of personal protective equipment (PPE), lack of annual policy review, unsanitary medication and treatment carts, inadequate hand hygiene during feeding, and improper separation of clean and soiled meal trays. Surveyors observed a medication cart on B Hall with an open coffee and an energy drink on top, and the RN interviewed acknowledged that open drinks should not be on the cart. A treatment cart on D Hall was observed with dark rings resembling coffee stains and visible dust and debris under glove boxes, and another treatment cart on B Hall had disposable cups and straws on top with food crumbs and debris in and around the glove rack; an RN stated CNAs used the cart as an extra surface when passing meals, even though it housed wound care supplies. The facility failed to timely initiate EBP for several residents who met criteria under the facility’s own EBP policy. Residents with surgical wounds, pressure ulcers, dialysis catheters, and indwelling urinary catheters had EBP orders initiated days to weeks after admission or after the condition was present. One resident admitted with a right tibia/fibula fracture and a surgical incision to the right leg had no EBP signage or PPE cart outside the room, and the EBP order was not entered until three days after admission. Another resident with a left tibia/fibula fracture, diabetes, chronic kidney disease, and a dialysis port had no EBP signage or PPE cart outside the room, and the EBP order was also delayed until 12 days after admission. Additional residents with a stage 2 pressure ulcer present on admission, a neck surgical incision, acute kidney failure with an indwelling catheter, and a right femur fracture requiring surgery all had EBP orders initiated between 3 and 14 days after admission or after the qualifying condition was documented. Surveyors also observed staff not properly donning PPE when providing care to residents under EBP. An occupational therapist provided physical therapy to a resident with a surgical incision without wearing a gown, and an LPN removed a leg brace from another EBP resident without a gown, later stating he did not realize the resident was on EBP. In another instance, a CNA was seen pushing PPE carts into two residents’ rooms while a unit manager placed EBP signs on their doors, indicating EBP implementation was occurring well after the presence of surgical wounds and ongoing dressing changes documented in the medical record. Hand hygiene and food service practices were also deficient. During a lunch meal, a CNA assisted three different residents with feeding, moving between them, handling different utensils, cups, plates, trays, and clothing protectors without performing hand hygiene at any time; when questioned, the CNA was unsure if hand hygiene was required between residents. During meal service on two different halls, food carts were observed containing both unserved meal trays and soiled trays together, with some soiled trays placed above or directly next to unserved trays, blocking service. CNAs who opened the carts acknowledged that dirty trays were not supposed to be placed with new trays. The facility’s hand hygiene policy required all staff to perform proper hand hygiene to prevent the spread of infection, and the FDA Food Code cited in the report requires food to be protected from cross contamination by proper arrangement and separation. The facility’s infection prevention and control program policies, including the Infection Prevention and Control Program Policy and Procedures, Antibiotic Stewardship Program Policy, Influenza Vaccine Policy, and Pneumococcal Vaccine Policy, were reviewed/revised in late 2023, and the Infection Prevention and Control Program policy required an annual review of the program and associated policies. The infection preventionist acknowledged that delayed EBP implementation often occurred when she was out of the facility because there was no designated backup to oversee the process, and confirmed that the provided infection prevention and control policies were the most up-to-date versions available. These findings collectively demonstrate failures to implement and operationalize the infection prevention and control program as written, including timely EBP initiation, consistent PPE use, maintenance of sanitary carts, adherence to hand hygiene, and proper separation of clean and soiled food trays.
Failure to Maintain Cleanliness and Repair of Resident and Common Areas
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain general cleanliness and repair of the environment, affecting resident, staff, and public areas. In the front entrance foyer across from the front door, a pink “Caution Wet Floor” sign was observed on the floor next to a waste container that contained a couple of inches of water, and the ceiling around the skylight above this area showed visible water damage. During an interview, the Maintenance Director stated he had attempted to repair the roof several times but was instructed to stop further repairs due to concerns about voiding the roof warranty. Additional observations on the D hall included a soiled bathroom floor shared between rooms D14 and D16, with chipped and worn paint along the bottom of the bathroom door and door frame, damaged walls and missing paint in room D11 exposing bare plaster, missing wall paint in room D9, and cove base molding peeled away from the wall in room D5. These conditions collectively demonstrated a lack of adequate upkeep and cleanliness of the physical environment in multiple resident-use areas within the facility.
Failure to Provide Homelike Dining Environment Due to Use of Plastic Utensils
Penalty
Summary
Surveyors identified that the facility failed to provide a homelike dining environment when serving meals with disposable plastic utensils instead of standard silverware. During a lunch observation on 2/8/2026, meals on A Hall and B Hall were delivered on trays from food carts, and each tray included only disposable plastic utensils. CNA R reported that disposable plastic utensils often came on the trays and explained that sometimes meal trays sat near the kitchen door in the dining room and did not get washed in time for the next meal. During a breakfast observation on 2/9/2026, meals were again delivered on trays from food carts, and on A Hall each tray included regular forks and spoons but plastic disposable knives. In an interview on 2/11/2026, the Food Service Manager (Staff C) stated that trays went down the hall and did not come back in time to be washed for the next meal, and he believed residents were keeping the silverware. Staff C acknowledged he was aware disposable plastic utensils were being used and that he had not ordered any more silver utensils. In a confidential group interview on 2/9/2026, five residents expressed frustration with the plastic cutlery used at mealtimes, with one resident stating that a plastic knife would not cut the meat. A complaint submitted to the State Agency on 12/29/2025 also reported that meals were never adequately served due to limited utensils. The facility’s policy on Residents’ Rights and Quality of Life, reviewed 1/1/2022, stated that all residents have the right to a dignified existence.
Failure to Provide Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure meals were palatable and served at preferred and appetizing temperatures, as evidenced by resident interviews, resident council minutes, and direct observation of food temperatures. In a confidential group interview, six of nine residents reported that food delivered at mealtimes was often cold, with one resident stating it was sometimes cold and other times lukewarm. Residents reported that meal trays sat in the serving window or in delivery carts for extended periods, contributing to cold food temperatures. One resident described purchasing hairnets online in an attempt to help deliver trays due to ongoing staffing problems and expressed distress that the facility would not allow this, noting that trays frequently stacked up in the serving window because there were not enough staff to deliver them promptly. Resident council meeting minutes over multiple months documented ongoing, unresolved complaints about cold or lukewarm food and beverages, including room trays, dining room meals, and coffee that was sometimes pre-poured and served lukewarm or cold. A cognitively intact resident with a history of left tibia/fibula fractures, who required staff assistance for bathing and toileting, reported that both breakfast and lunch were cold and that this occurred frequently because staff were late checking blood sugar. During observation of a lunch meal service on A Hall, surveyors measured the temperatures of items on the last tray from a food cart and found milk and juice at 59 degrees Fahrenheit and hot items (chicken breast and sliced cooked carrots) at 106–107 degrees Fahrenheit, which did not meet the FDA Food Code standards for hot and cold holding. The facility’s own policy required prompt meal service with resident preferences accommodated, but the observations and interviews showed this was not consistently achieved.
Failure to Honor Food Preferences, Standing Orders, and Always Available Menu Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to honor resident food preferences, standing diet orders, and to offer substitutes or alternative menu items as ordered or documented. During meal observations, multiple residents did not receive the type or amount of juice specified on their tray cards, including residents whose cards called for 8 fl oz of assorted or apple juice but who received only 4 fl oz, and one resident whose card specified certain acceptable vegetables but who was served carrots without an alternative vegetable. Another resident whose tray card allowed deli meat and specified an alternative meal of ham or turkey sandwich instead received a peanut butter and jelly sandwich. A resident who was supposed to receive two bowls of soup when no selective menu was filled out did not receive any soup, and several residents who requested hot dogs from the Always Available menu instead received hamburgers. Additional observations showed that condiments and beverage additions documented as standing orders were not provided. One resident’s tray card specified cream and sugar substitute, but the tray arrived without cream, sugar substitute, salt, or pepper, despite staff acknowledging the resident would want these items. Several residents with tray cards indicating “extra sauces or gravy” or “sauce/gravy on all meats” received dry ground or chopped meat without sauce or gravy; one of these residents reported the meat was too dry, did not like it, and ate only a sip of milk and part of a muffin. At breakfast, a resident who had handwritten yogurt on a selective menu did not receive yogurt and stated this had happened before, and another resident whose standing orders included a daily banana did not receive one, although other residents had bananas and the resident stated he would like one. Surveyors also noted failures to offer substitutes when meals were not eaten and ongoing, unresolved food availability issues. One resident with malnutrition and severe cognitive impairment had a breakfast tray placed out of reach and did not eat any of the food before a hospitality aide removed the tray without offering any substitutes or alternatives. Another cognitively intact resident had a meal tray removed by an LPN without being offered any food or beverage substitutes or alternative menu items. In a confidential group interview, four residents reported the facility frequently ran out of preferred items listed on the Always Available menu, including ice cream, yogurt, pudding, cookies, hamburgers, and hot dogs; one resident requiring a gluten-free diet reported being served salad for two meals a day, five days per week and expressed frustration, stating they wanted anything other than salad. Resident council minutes over several months documented repeated, unresolved complaints that residents continued to receive foods listed as dislikes on their meal tickets and that the kitchen repeatedly ran out of requested items such as hamburgers, hot dogs, tomato juice, hot chocolate, ice cream, creamer, sweetener, and cottage cheese.
Failure to Protect Resident’s Personal Narcotic Medication From Misappropriation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s belongings, specifically prescription pain medication, from misappropriation. A cognitively intact resident with a left tibia/fibula fracture was admitted with personal belongings, and later reported that four hydrocodone/acetaminophen tablets she had brought in her purse from home were missing when she wanted to take one for increased pain. The resident’s admission inventory sheet did not list any medications, and the facility’s own summary documented that the resident told the administrator she had a bottle in her purse with four hydrocodone tablets that were now gone, stating that a “skinny little nurse probably took them last night.” The facility’s abuse, neglect, and exploitation policy required protections against misappropriation of resident property, but the DON stated she was unsure whether nurses asked about medications during admission, indicating that medications brought from home were not consistently inventoried. Multiple staff interviews described a nurse (RN AA) working on the same unit who appeared to be under the influence while on duty, raising concerns about medication handling and resident safety. Staff reported that this nurse was not passing medications as expected, was weaving and wobbling, had uncontrolled facial movements, was found asleep at the medication cart, and required other staff to notify the NHA and remove her medication cart keys. CNAs and another nurse stated that residents commented the nurse was “cooked” and “wiped out,” and one staff member reported that another resident received the wrong medications. A confidential resident also described the nurse as being “higher than a [NAME]” and “F**ked up,” hiding in an alcove. The NHA confirmed that the nurse was behaving out of the ordinary and was terminated after refusing a drug test. The facility’s internal summary of the missing narcotic documented that the resident’s admission inventory did not reflect any medications from home, despite the resident’s report that she had brought hydrocodone in her purse. When the administrator later examined the purse, an empty hydrocodone bottle and other medications (gabapentin and ondansetron) were found and counted, and a subsequent room search with the resident’s permission revealed marijuana gummies, cigarettes, and a lighter. These findings, combined with the lack of documented medication inventory at admission and the presence of a nurse suspected by multiple staff and a resident of being under the influence while having access to medications, demonstrate the facility’s failure to protect the resident’s property from potential misappropriation as required by its abuse, neglect, and exploitation policy.
Failure to Timely Report Alleged Misappropriation of Controlled Pain Medication
Penalty
Summary
The facility failed to implement its policies and procedures for timely reporting of a reasonable suspicion of a crime related to misappropriation of a resident’s controlled pain medication. A cognitively intact resident, admitted with a left tibia/fibula fracture and prescribed hydrocodone/acetaminophen for pain, reported that a night shift nurse had taken four of her hydrocodone 10 mg/325 mg tablets, which she had brought from home in her purse. The resident stated this concern to staff at approximately 5:30 PM on a Saturday, and the DON documented in a progress note that the administrator and a nurse spoke with the resident about the missing Norco. Despite this allegation of misappropriation of narcotic medication, the NHA acknowledged in an interview that the allegation was not reported to the state agency at that time. The deficiency was further supported by the timing of the report to the state agency compared with when the allegation was known to facility staff. The state agency report, dated 2/8/26 at 4:47 PM, listed the misappropriation incident as discovered on 2/7/26 at 5:26 PM, indicating late reporting. The resident had already reported the missing medication to the surveyor on 2/7/26 at 2:15 PM, and the surveyor alerted the DON at 2:20 PM that same day. Facility policy on Abuse, Neglect, and Exploitation required reporting all violations to the administrator, state agency, adult protective services, and other required agencies within specified timeframes, including not later than 24 hours for events that do not involve abuse and do not result in serious bodily injury. The facility did not follow this policy or the requirements of section 1150B of the Act in reporting the reasonable suspicion of a crime involving misappropriation of the resident’s property.
Failure to Investigate Alleged Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to implement its abuse, neglect, and exploitation policy requiring immediate and thorough investigation of alleged misappropriation of resident property, specifically narcotic medication. A cognitively intact resident, admitted with a left tibia/fibula fracture, reported that a night shift nurse took four hydrocodone/acetaminophen tablets that the resident stated she had brought from the hospital and kept in her purse. The resident reported increased pain and a desire to take one of the missing pills. A progress note by the DON documented that the resident had raised the concern about four missing Norco tablets in her purse. The facility’s written policy required immediate investigation of suspected abuse, neglect, exploitation, or misappropriation, including investigating different types of alleged violations, identifying and interviewing all involved persons and potential witnesses, and providing complete and thorough documentation of the investigation. Surveyor review and interviews showed that these investigative steps were not carried out as required. When asked on multiple occasions, the DON could not initially provide documentation of an investigation into the alleged misappropriation of narcotics. Later, a summary of the event was produced by the RDO, but review of staff interviews and staffing schedules revealed that 16 staff members who could have relevant information were not interviewed regarding the allegation. Additionally, the DON stated she was unsure whether nurses asked about medications during the admission process and only knew that care assistants inventoried clothing, indicating that resident medications were not consistently inventoried on admission. This lack of comprehensive interviews, incomplete documentation, and absence of a clear process for identifying and accounting for resident medications on admission demonstrated the facility’s failure to follow its own policies and procedures for investigating alleged misappropriation of resident property.
Failure to Provide Individualized ADL Care and Personal Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide individualized ADL care, including repositioning, grooming, toileting, and bathing, in accordance with residents’ assessed needs and preferences. One resident with depression, anxiety, malnutrition, osteoporosis, and identified as at risk for pressure ulcers had an MDS indicating a need for supervision/touching assistance with turning and repositioning in bed. During a two-hour observation period, this resident remained lying on her back with the head of the bed slightly elevated, and no staff entered the room to assist or encourage her to turn or reposition. Another resident with diabetes mellitus and a hip fracture, who was cognitively intact, was observed lying in bed with long facial hair. He reported he had not been shaved in a long time and could not recall when he was last shaved, and stated that long facial hair made him feel dirty. A CNA stated residents were supposed to be shaved on admission, on shower days, or upon request, while another CNA reported that at times residents did not receive the care they deserved due to insufficient staffing and that residents were neglected. A third cognitively intact resident with a left tibia/fibula fracture, diabetes mellitus, and chronic kidney disease requiring dialysis was dependent on staff for bathing and required staff assistance for toileting. This resident reported having been left wet and soiled in urine and fecal matter for over two hours one morning, describing the experience as mortifying and nasty. She also reported not having received a shower during her two-week stay and that staff hardly got her up into a chair; at the time of observation, her hair was disheveled. Her documented preferences indicated it was very important to her to choose her bathing method and that she preferred showers, but her ADL care plan did not include bathing interventions. Review of her shower task list showed missed showers on multiple scheduled days, and a CNA confirmed she had not received any showers since admission, citing lack of shower sheets and frequent call-ins on scheduled shower days. These findings occurred despite facility policies stating that residents would be treated with dignity and receive necessary services to maintain grooming and personal hygiene.
Failure to Complete Timely Admission Assessment and Initiate Bowel Protocols
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessments and care according to orders and residents’ needs, including failure to complete an admission assessment and to initiate bowel protocols for constipation. One resident was admitted in the evening and reported that upon arrival staff briefly entered and left the room without explanation, and no vital signs, blood pressure, or head-to-toe assessment were performed at the time of admission. The resident, who was cognitively intact with a BIMS score of 15/15 and had a recent leg fracture limiting mobility, documented in a notebook that she lay in bed without understanding what was happening, needed pillows to elevate her legs, and did not receive dinner when told it was on the way. She also reported using the call light during the first night, which remained on for a long period without response, leading her to call the facility’s main phone number, which was answered first by one resident and then handed to another resident before staff eventually came to her room. Record review for this resident showed she was admitted on one date and that the nursing assessment was not started until nearly six hours later and was not completed. Facility policy on admission orders required that a physician or other qualified practitioner provide orders for immediate care needs, including diet and other care-related orders, to allow staff to provide essential care. In interviews, an RN stated that on admission nurses are expected to settle the resident in the room, add a diet order, perform a head-to-toe assessment, obtain vital signs, complete a skin assessment, notify the physician, and write an admission note when the resident first arrives. The DON confirmed that nursing staff are expected to complete an assessment within the first hour of admission and obtain vital signs immediately, which did not occur for this resident. The facility also failed to initiate bowel protocols in a timely manner for two residents with documented constipation and available PRN and scheduled bowel medications. One resident with diagnoses including diabetes, a Stage 2 sacral pressure ulcer, left hip fracture, mesenteric artery stenosis, and constipation reported not having a bowel movement for four days and expressed concern that no treatment had been provided, while a family member confirmed they had alerted nursing the previous day. The following day, the resident continued to report no bowel movement, nausea, and abdominal discomfort, and the family member stated a nurse had been informed and said she would call the physician. EMR review showed no bowel movement documented from admission through several days later, despite frequent administration of opioid pain medication. PRN Milk of Magnesia ordered for no bowel movement in three days was not given until day five without documented use of subsequent PRN Dulcolax suppository or Fleet enema, and scheduled daily laxative and stool softener orders were not started until more than five days after admission. Another resident with demyelinating disease of the CNS, osteoporosis, arthritis, generalized weakness, and frequent falls, and with mild cognitive impairment (BIMS 13/15), was observed nauseated, declining breakfast and lunch, and unsure of the date of the last bowel movement. Bowel elimination documentation showed the last bowel movement occurred five days earlier, with repeated entries of no bowel movement through the date of review. There was no documented bowel assessment corresponding to the resident’s nausea or the prolonged absence of a bowel movement. Although multiple PRN bowel medications (Milk of Magnesia, Metamucil, Dulcolax suppository, Fleet enema) were ordered, none were documented as administered during the review period. The DON reported that night shift was supposed to pull bowel elimination reports and pass information to oncoming staff, but acknowledged the reports were not consistently provided and that a nurse did not receive a bowel protocol list due to staff being busy with multiple new admissions, and also stated there was no facility policy related to bowel protocol.
Failure to Implement Fall Interventions and Enforce Safe Smoking Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain required fall-prevention interventions for one resident and to ensure safe smoking practices for another resident. One resident with a seizure disorder, fracture history, anxiety disorder, and moderate cognitive impairment had a care plan focus identifying risk for falls and injury, with an intervention specifying fall mats on both sides of the bed initiated months earlier. During observation, the resident’s bed was in a high position and the two floor mats were found folded behind a chair in another resident’s room, not on the floor beside the bed as ordered. A CNA who had been on duty since early morning reported the floor mats were not in place at the start of the shift, stated that the mats were supposed to be on both sides of the bed due to a previous fall, and noted she could not view the care plan on the computer. An RN confirmed the mats were required per the care plan and acknowledged the intervention was not set up as a CNA task, which was described as concerning given the number of new staff unfamiliar with the residents. The NHA also acknowledged concern about the missing floor mat intervention. The facility’s fall prevention policy required assessment of fall risk, development of a comprehensive plan of care including environmental hazards, and monitoring of interventions for effectiveness. The deficiency also includes failure to ensure safe smoking practices for a resident with difficulty walking, need for assistance with personal care, tobacco use, and moderate cognitive impairment. The resident was observed returning from outside in very cold, snowy conditions, wearing a heavy coat and gloves with snow on them, after going out to smoke. A CNA stated the resident went out to smoke, was “his own person,” and was supposed to go off premises, though acknowledged that in winter the resident could not traverse the deep snow and instead smoked just outside the door. Staff reported the resident smoked as often as possible, approximately every two to four hours, and that he had his own cigarettes and lighter. They also stated he was supposed to sign himself out in a lobby sign-out book, which was not present in the lobby at the time of observation. Later, the NHA was found holding the sign-out book along with the resident’s lighter and cigarettes, confirmed the items belonged to the resident, and stated the campus was non-smoking and residents could smoke off premises using the sign-out process. Review of the sign-out book showed only a few entries, all by this resident, despite staff reports that he smoked many times daily. The facility’s smoking policy stated that smoking was not permitted on facility property and that residents with smoking privileges may not retain smoking articles on their person or in their living or sleeping area at any time.
Failure to Implement Timely Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement timely and appropriate pressure ulcer prevention and treatment interventions for two residents, resulting in the development and worsening of pressure injuries. One resident was admitted with diagnoses including Alzheimer’s disease, adult failure to thrive, weakness, and cognitive communication deficit, and was identified on admission as having bilateral lower leg wounds, scabs/bruising on both arms, bowel incontinence, and being at risk for skin impairment. A Braden Scale score of 15 indicated risk for pressure ulcers, and the admission evaluation identified the need for a pressure redistribution mattress to the bed. Initially, a physician note documented no open wounds, but within days, moisture-associated skin damage (MASD) was identified on the bilateral buttocks, with red, eroded skin and loose stools. Nursing documentation over subsequent days repeatedly described shearing and deterioration of the buttocks, including purple areas and scattered open superficial areas, while the resident continued to have very loose stools. Despite ongoing documentation of worsening buttock skin breakdown and the resident’s high risk factors (failure to thrive, incontinence, limited mobility), there was no timely implementation of a low air loss mattress. The facility’s own policy stated that evidence-based interventions, including moisture management and appropriate pressure-redistributing support surfaces, should be implemented for residents at risk or with existing pressure injuries. The low air loss mattress was not ordered until mid-October, after documentation that the buttocks were deteriorating, and the order required maintenance to place the mattress. Maintenance staff reported that work orders are generally completed within 48 hours and that there is no retrievable record once completed. The DON acknowledged that moisture from bowel incontinence increases pressure ulcer risk and that failure to thrive is an indication for a low air loss mattress, and confirmed that a physician order was required before placement. However, review of MARs, TARs, and POC documentation showed no order, application, or monitoring of a low air loss mattress during the period when the wounds were progressing from MASD to suspected deep tissue injury and then to unstageable pressure ulcers. Physician progress notes documented that the resident’s buttock wounds progressed from MASD to suspected deep tissue wounds with slough/eschar, and then to unstageable pressure ulcers with nearly 100% black necrotic tissue, purulence, erythema, and induration concerning for wound infection or necrotizing fasciitis. The resident was transferred to the hospital, where an emergency department exam found a necrotizing, foul-smelling sacral and bilateral buttock wound, with imaging and labs consistent with a severe infected decubitus ulcer. The resident required urgent surgical incision and debridement, ICU admission, IV antibiotics, and had a large surgical dressing with wound VAC at discharge. Facility work order records later showed that the low air loss mattress ordered in mid-October was not documented as placed until early November, after the resident had been hospitalized and surgically treated, indicating a significant delay between identification of worsening wounds and implementation of this pressure-redistributing support surface. The second resident was admitted with diagnoses including diabetes, adult failure to thrive, dehydration, difficulty walking, and osteoarthritis, and was documented on admission as having a right buttock rash, a left buttock blister, and pressure wounds on the right rear thigh and left gluteus. The admission nursing evaluation identified the need for a pressure redistribution mattress to the bed as an intervention. An MDS assessment showed the resident required substantial/maximal assistance with bed mobility, was dependent for transfers, had a stage 2 pressure ulcer, and was at risk for developing pressure injuries. However, review of physician orders from admission through the survey date revealed no order for a low air loss mattress, and observations on multiple occasions showed the resident in bed without a low air loss mattress, seated directly on the buttocks without a wedge or positioning device for offloading, and with heels resting directly on the mattress. During observations, heel protection boots were seen on the nightstand rather than on the resident’s feet, and the resident reported that staff did not put the boots on because they bothered her and that a pillow was used instead. The resident also reported having an open wound on the left outer thigh. Nursing staff confirmed that the resident was fearful of turning and repositioning, had significant left knee pain, could not consistently move or reposition herself in bed, did not like to wear heel boots, and was at risk for further pressure injuries. The unit manager stated she was unaware of the resident’s refusal to wear heel protection boots but acknowledged that the resident’s admission with pressure injuries placed her at higher risk for future wounds. Across both residents, the facility did not consistently translate identified risk factors, documented skin breakdown, and care plan recommendations (such as pressure redistribution mattress and heel protection) into timely, ordered, and implemented interventions to prevent the development and worsening of pressure ulcers. The facility’s pressure injury prevention policy defined avoidable pressure injuries as those occurring when the facility fails to evaluate clinical condition and risk factors, and to define and implement interventions consistent with resident needs, goals, and professional standards of practice. The policy specified that interventions should be based on risk and skin assessments and that evidence-based interventions, including minimizing moisture exposure and providing appropriate pressure-redistributing support surfaces, should be implemented for all residents at risk or with existing pressure injuries. In the cases of these two residents, the documented sequence of assessments, nursing notes, physician notes, and observations showed that the facility did not timely implement or consistently use pressure-redistributing mattresses, offloading devices, and moisture management strategies in accordance with the residents’ identified risks and existing wounds, leading to the cited deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Provide Timely Wound Care and Communication for Post-Operative Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide timely and appropriate wound care, accurate documentation, and effective communication regarding a post-operative surgical site for a resident admitted with multiple complex medical conditions, including a recent lumbar fusion, right hip fracture, diabetes, and adrenal insufficiency. Upon admission, the initial skin assessment did not document the resident's post-operative back incision, despite its presence and the need for ongoing care. Physician orders for wound care to the central lower back were not implemented until the third day after admission, and there were missed dressing changes on subsequent days, with no corresponding nursing notes to explain the omissions. The resident reported increased pain and drainage from the back incision, and there was evidence of wound dehiscence documented in progress notes. However, the facility failed to notify the physician or nurse practitioner of the change in the wound's condition, and the provider was not made aware of the dehiscence. The resident and her family had to advocate for wound assessment and care, and ultimately, the back surgeon's office instructed the resident to seek emergency care after reviewing a photo of the wound. The lack of timely wound care, incomplete documentation, and failure to communicate changes in the wound's condition resulted in the resident developing a surgical site infection that required hospital admission, surgical washout, intravenous antibiotics, and an extended course of oral antibiotics. Facility policy required wound treatments to be provided according to physician orders and for nurses to notify the physician in the absence of orders, but these procedures were not followed in this case.
Failure to Maintain Sanitary Shower Room Due to Mold
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the D-hall community shower room, as evidenced by the presence of mold along the base of the shower and around the drain. A complainant who recently stayed at the facility reported seeing mold in the shower area, describing it as 'disgusting' and expressing discomfort with the cleanliness. The complainant stated they were relieved to use a shower chair to avoid direct contact with the floor. Direct observation confirmed the presence of mold in the specified areas of the shower room. Interviews with staff revealed that the shower room was reportedly cleaned daily and deep cleaned monthly, with documentation showing the last deep cleaning occurred six days prior to the observation. However, the housekeeper responsible for the deep cleaning did not notice the mold, and was unable to articulate the appropriate response if mold was found. The maintenance director and regional director of operations both confirmed they had not received any notifications or work orders regarding mold in the shower rooms. The nursing home administrator acknowledged the presence of mold and stated that the shower rooms should not have mold and require re-caulking.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from abuse, specifically sexual abuse, involving four residents. The incidents involved a resident with moderate cognitive impairment who engaged in inappropriate touching of other residents, including kissing one resident on the cheek, touching another on the thigh, and touching the breast of a third resident. These actions were reported to the State Agency as abuse. The residents involved had varying levels of cognitive impairment, with some having severe cognitive deficits, making them unable to consent to such interactions. Staff members, including CNAs, witnessed these incidents and reported them to the Nursing Home Administrator. Despite these reports, there was no evaluation conducted to determine the capacity of the affected residents to consent to the advances. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated incidents and lack of immediate intervention to prevent further occurrences. The facility's failure to establish a safe environment and adequately address the inappropriate behavior led to the deficiency.
Inadequate Investigation of Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of sexual abuse involving a resident, identified as R20, who was reported to have inappropriate physical interactions with other residents. The incidents included R20 kissing a resident on the cheek, touching another resident on the thigh, and further inappropriate touching of other residents. Despite these reports, the facility's investigation was incomplete, lacking detailed witness statements and failing to document the specifics of the incidents, such as the date, time, and location. Witness statements were inconsistent, with some lacking signatures and others not being included in the investigation file. The Nursing Home Administrator (NHA) acknowledged the deficiencies in the investigation process, including the absence of detailed documentation and the inability to recall specific details about the incidents. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and thorough documentation, which was not adhered to in this case. This failure to properly investigate and document the incidents resulted in a potential risk for additional exposure to sexual abuse for other cognitively impaired residents.
Staffing Deficiencies Lead to Unmet Resident Needs
Penalty
Summary
The facility failed to maintain sufficient nursing staff, as evidenced by interviews with residents, family members, and staff, as well as a review of payroll data. The Payroll-Based Journal (PBJ) report indicated low staffing levels and a one-star staffing rating for the fourth quarter. The facility's Facility Assessment Tool outlined specific staffing requirements based on resident acuity, but these were not met on multiple occasions. For instance, on several dates, the number of Certified Nursing Assistants (CNAs) scheduled was below the required levels, with instances of no call no shows and staff not being available, leading to inadequate coverage for the four halls in the facility. Interviews with staff and residents highlighted the impact of the staffing deficiencies. A CNA reported that the facility was short-staffed 85% of the time, particularly on weekends, and noted that monetary incentives to cover shifts were not typically offered. Residents expressed concerns about delayed responses to call lights and unmet care needs, with one resident stating they sometimes had no choice but to soil themselves due to long wait times. Family members also reported similar issues, with one noting that their relative had been left in the same clothes for four days and experienced a stomachache without receiving timely assistance. These findings indicate that the facility's staffing levels did not adequately account for resident acuity or care needs, resulting in unmet resident needs and distress.
Failure to Maintain Safe and Sanitary Conditions for Personal Refrigerators
Penalty
Summary
The facility failed to provide a safe and sanitary environment for six residents who had personal refrigerators in their rooms. During an observation, it was noted that these refrigerators stored both perishable and non-perishable foods, but none were equipped with thermometers, and no temperature logs were maintained. The internal temperatures of these refrigerators varied between 37 F and 54 F, which could lead to food spoilage. The facility did not have a comprehensive list of residents with personal refrigerators, as only three out of the six rooms with refrigerators were identified by the facility. The facility had a policy in place for the use of personal refrigerators, which included requirements for maintenance inspections, temperature monitoring, and safe food handling practices. However, these policies were not being followed. Housekeeping staff were supposed to record refrigerator temperatures daily and clean the refrigerators, but the housekeeping supervisor confirmed that this was not being done. This lack of adherence to the policy contributed to the unsanitary conditions observed in the residents' rooms.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents, as evidenced by improper storage and labeling of respiratory equipment, failure to provide supplemental oxygen as per physician's orders, and lack of documentation for CPAP therapy. Resident #31 was observed with a nasal cannula dated 12/25/24, and the oxygen concentrator was set incorrectly at 3 liters per minute instead of the ordered 2 liters per minute. The resident was unaware of who changed the flow rate, and the oxygen tubing was not changed weekly as ordered. Resident #46 had a CPAP machine without a physician's order or documentation for its use and maintenance. The CPAP mask was not stored properly, lacking a bag or barrier. The only record of the CPAP was a progress note from 9/13/24, with no further documentation on settings or maintenance. Similarly, Resident #7 had a CPAP without a physician's order or care plan, and the mask was improperly stored. Resident #57 was observed using a nasal cannula with an oxygen concentrator set at 10 liters per minute, but the bubbler reservoir was empty, causing discomfort. There were no physician's orders for oxygen use or maintenance, and the resident had been using oxygen since admission. The facility's policies required physician orders for oxygen and CPAP use, and the Director of Nursing confirmed these expectations were not met, leading to deficiencies in respiratory care for these residents.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to secure medications properly, as observed during a survey. An unlocked and unattended treatment cart was found on the A-hall, containing eight topical medication creams and various wound care supplies, including an opened bottle of normal saline without a date of opening. Additionally, a topical medication cream, Nystatin, was found in a resident's bathroom, despite the resident's quarterly nursing assessment indicating that she did not wish to self-administer medications. This resident was cognitively impaired and sitting in her wheelchair at the time of the observation. Further observations revealed issues with the D-hall medication cart, which contained a medication cup of crushed medications unlabeled for an unidentified resident, and several loose pills identified as escitalopram, sucralfate, nifedipine, and aspirin. Additionally, a water bottle with a red substance, identified as the floor nurse's beverage, was stored in the bottom drawer of the medication cart. The facility's policy on medication storage requires all drugs and biologicals to be stored in locked compartments, which was not adhered to in these instances.
Failure to Update Care Plans Appropriately
Penalty
Summary
The facility failed to ensure care plans were updated promptly and revised appropriately for four residents, leading to care plans that did not reflect the residents' needs. For Resident 15, a care plan was updated two months after an altercation with another resident, but the update was unclear to staff, as they could not identify the resident to be avoided. The Regional Clinical RN admitted to not updating the care plan at the time of the incident. Resident 24's care plan was not updated following multiple hospitalizations due to catheter issues. Despite a hospitalization for continuous bleeding around the catheter, the care plan lacked updated interventions to prevent further dislodging and rehospitalization. The RN acknowledged the absence of updated interventions in the care plan. Resident 25's care plan did not include interventions to prevent further decline of contractures or negative outcomes due to contractures. The DON confirmed the lack of care plan details for managing the resident's contractures. Additionally, Resident 36's care plan was not updated following an altercation with another resident, despite the DON's initial claim that it had been updated. The DON later acknowledged the oversight.
Verbal Abuse Incident Involving a Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse, resulting in mental distress and anguish. The incident involved a resident with a history of cerebral infarction, dementia, muscle weakness, and difficulty walking, who required assistance with personal care. The resident, identified as having moderate cognitive impairment, was subjected to verbal abuse by a Certified Nursing Assistant (CNA N) who yelled and used inappropriate language after the resident had an accident in their pants. This incident was reported by another CNA (CNA M) who intervened after being informed by two non-certified aides who overheard the altercation. Interviews conducted with the resident and multiple staff members confirmed the details of the incident. The resident expressed feeling bad about the situation, and staff members corroborated the use of vulgar language by CNA N. The facility's policy on abuse, neglect, and exploitation, which aims to protect residents' health, welfare, and rights, was not adhered to in this instance, leading to the deficiency. The Nursing Home Administrator acknowledged the unacceptable behavior of CNA N, which was verified by other staff members, including a Regional Clinical Nurse.
Failure to Provide Appropriate ROM Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion for a resident with severe cognitive impairment and contractures. The resident, who was admitted with diagnoses including cerebral palsy, contractures, lack of coordination, and dementia, was observed on multiple occasions without any protective devices in place to prevent skin breakdown in his contracted fists. Despite being on the facility's case load for contracture treatment until September 2, 2024, the resident had not received any treatment since that date, and no interventions were documented in the care plan to prevent further decline. Interviews with facility staff revealed that the resident was supposed to be included in a restorative program, but it had not yet been implemented. The Director of Rehabilitation acknowledged the lack of ongoing treatment and the need for restorative therapy, while the Regional Clinical RN confirmed that the facility was in the process of developing a restorative program. The facility's policy on Restorative Nursing Programs, last reviewed in January 2022, indicated that residents with contractures could benefit from such programs, yet no actions had been taken to address the resident's needs.
Failure to Provide Adequate Social Services After Resident Altercation
Penalty
Summary
The facility failed to provide adequate medically related social services for a resident with severe cognitive impairment, as evidenced by an incident involving resident-to-resident aggression. The resident, who has diagnoses including dementia and a cognitive communication deficit, was involved in an altercation where they scratched another resident. Despite the incident being reported and documented, the resident's care plan was not updated to address the behavior, and there was no evidence of follow-up by social services. Interviews with the Director of Nursing and the Social Services Director revealed that the expected follow-up actions, such as updating the care plan and documenting social services interventions, were not completed. The facility's policy on behavior management requires the identification of target behaviors and the development of an individualized plan of care, which was not adhered to in this case. The lack of documentation and follow-up indicates a deficiency in providing necessary social services to ensure the resident's psychosocial stability and prevent further altercations.
Medication Administration Errors Result in 11.54% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 11.54%. This was identified during a medication administration observation involving a resident with diagnoses including diabetes mellitus, heart disease, sleep apnea, and hypertension. The resident had a BIMS score indicating intact cognition. During the medication pass, a registered nurse (RN) administered two types of insulin and a carvedilol tablet. However, the RN did not hold the insulin pen needles in place for the recommended time, leading to leakage from the injection sites. Additionally, the RN administered carvedilol despite the resident's blood pressure being below the prescribed parameters. The RN was unaware of the blood pressure parameters for the carvedilol and expressed surprise that the computer system allowed the medication to be administered outside the specified range. The facility's policy on medication administration requires adherence to physician orders and manufacturer specifications, including holding medications for vital signs outside prescribed parameters. The RN's actions resulted in three medication errors: two related to improper insulin administration and one related to administering carvedilol outside the prescribed blood pressure parameters.
Inadequate Infection Control Practices and PPE Use
Penalty
Summary
The facility failed to ensure effective infection control practices and the appropriate use of personal protective equipment (PPE) for two residents, resulting in the potential transmission of communicable diseases to all 74 residents. Observations revealed that rooms of residents with COVID-19 had open doors despite signage indicating the need for closed doors under airborne precautions. The signage did not specify which resident required which type of isolation, leading to confusion among staff, particularly those unfamiliar with the residents. Certified Nurse Aide (CNA) D, who was not usually assigned to the D-hall, was not informed about the specific precautions needed for residents with COVID-19, and Licensed Practical Nurse (LPN) F admitted that the CNA would not know unless informed by a nurse. The Director of Nursing (DON) and Regional Nurse K acknowledged the lack of clarity in the signage and the need for better processes to inform staff about isolation precautions. The care plans for the residents did not include interventions to keep the doors open, which was necessary for some residents requiring supervision. Additionally, PPE was not available inside the rooms, and staff were observed wearing PPE from one resident's room into the hallway, contrary to the facility's policy and CDC guidelines. CNA S was seen placing a meal tray on a dirty bin and using the same PPE for multiple residents, further indicating lapses in infection control practices. Housekeeper R was observed placing garbage bags on the floor in the hallway, which was against the facility's policy. The DON confirmed that refuse bags should be placed in larger containers and that PPE should be removed before exiting a resident's room. The facility's policies on COVID-19 prevention and transmission-based precautions were not adequately followed, as evidenced by the improper use of PPE and the failure to maintain closed doors for residents under airborne precautions.
Failure to Post Ombudsman Contact Information
Penalty
Summary
The facility failed to ensure that the contact information for the Office of the State Long-Term Care Ombudsman was posted in a manner accessible to residents and their representatives. This deficiency affected all 74 residents residing in the facility. During a confidential group meeting with eight residents, it was revealed that they were unfamiliar with the Ombudsman and did not know how to contact the office. Subsequent observations confirmed that the contact information for the Ombudsman was not posted. Interviews with the Nursing Home Administrator and the Assistant NHA revealed that there was no policy in place for posting this information.
Inaccurate Staffing Information Posted
Penalty
Summary
The facility failed to accurately reflect the actual hours worked by nursing staff, including nurses and certified nursing assistants, on their daily staffing postings. This deficiency was identified during a record review of the facility's daily staffing postings for specific dates, which revealed that the postings did not indicate the actual hours worked by staff for both day and night shifts. The postings were supposed to be updated 2 hours prior to the shift start but lacked adjustments for any changes, such as a nurse calling in sick. During an interview, the Director of Nursing (DON) acknowledged that the daily staffing posting included all staff present with hours worked, but it did not reflect adjustments for a nurse who was absent due to illness. This oversight resulted in necessary staffing information not being available to residents and visitors, potentially affecting all 74 residents within the facility.
Failure to Prevent and Respond to Resident Elopement
Penalty
Summary
The facility failed to prevent, detect, and respond to an elopement involving two residents, resulting in the likelihood of serious harm. On the evening of 7/13/24, two residents, one with severe cognitive impairment and the other with intact cognition, eloped from the facility undetected. They were later found on a roadway by a facility visitor. The residents were wearing Wanderguard bracelets, which were intended to prevent such incidents, but the bracelets were removed by one of the residents, and the facility's alarm system did not alert staff due to a visitor holding the door open. The incident was compounded by staff inaction and a lack of proper response to the alarm system. A Licensed Practical Nurse (LPN) and a Registered Nurse (RN) were notified by a visitor about the residents being outside, but they did not hear the alarm due to frequent alarm activations caused by visitors entering and exiting the facility. The alarm had become a normal background noise, leading to complacency among staff. Additionally, a Certified Nursing Assistant (CNA) turned off the door alarm without checking for residents, as it was common practice to silence the alarm without verifying the situation. The facility's documentation and reporting of the incident were also flawed. The Director of Nursing (DON) and the Regional Director of Operations initially reported inaccurate information regarding the residents' location and the alarm's status. The Regional Director of Operations admitted to not reviewing the video footage until much later and acknowledged assumptions made in the initial report. This lack of accurate reporting and investigation further highlights the facility's failure to adequately address and prevent the elopement incident.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent two separate incidents of resident-to-resident sexual abuse involving four residents. In the first incident, a resident with quadriplegia and PTSD was inappropriately touched by another resident with severe cognitive impairment in the dining room. Despite the resident's request to stop, the inappropriate behavior continued, causing the resident to feel embarrassed and anxious. The incident was reported to the police, and it was noted that the resident had a history of being a victim of sexual assault, which exacerbated the psychological harm experienced. The second incident involved a resident with Alzheimer's Disease and another resident with vascular dementia. A CNA discovered one resident with exposed genitalia and the other standing nearby, possibly performing peri-care. The CNA reported the incident to the floor nurse and the Regional Director of Clinical Services, but there was no documentation of the event in the residents' medical records. The floor nurse admitted to not documenting the incident due to being overwhelmed with responsibilities. The facility's policies on abuse prevention and trauma-informed care were not effectively implemented, as evidenced by the lack of updated care plans and interventions for residents with known behavioral issues. The resident involved in the first incident had a care plan that prohibited dining room presence, yet this was not enforced. Additionally, the facility's communication methods for alerting staff to residents' behavioral histories were inadequate, relying on word-of-mouth rather than documented protocols.
Failure to Report Employee's Criminal Conviction
Penalty
Summary
The facility failed to report an employee's criminal conviction to the State Agency, which could potentially jeopardize the safety and welfare of all 69 residents. The issue was identified during a complaint investigation related to an employee, referred to as Confidential Staff R, who had a criminal conviction for brandishing a firearm in public. This information was unknown to the facility administration at the time of the survey. A confidential staff member expressed concerns about the safety of the residents due to this conviction. During interviews, the Nursing Home Administrator and Regional Directors of Clinical Services stated they were unaware of the conviction, believing the charges had been dropped. Confidential Staff R confirmed the conviction and claimed that previous administration had been notified, but no evidence of such notification was provided. The facility's employee handbook requires employees to notify the Facility Administrator of any arrests or convictions, and the facility's policy mandates reporting any court actions indicating an employee is unfit for service to the state nurse aide registry or licensing authorities.
Staffing Deficiency Leads to Unmet Care Needs
Penalty
Summary
The facility failed to provide sufficient staffing to meet the care, needs, and safety of its residents, resulting in unmet care needs and potential safety issues for all 69 residents. On a specific night shift, only one LPN and three CNAs were available to care for 80 residents, with the Director of Nursing aware of the situation but failing to provide assistance. Timecard reviews confirmed that one LPN was the sole nurse on duty for 4.5 hours with a census of 77 residents, contrary to the facility's staffing plan that required three licensed nurses on the midnight shift. Interviews with staff and residents revealed ongoing concerns with understaffing, particularly during night shifts. Residents reported delays in receiving incontinence care, daily hygiene, and skin and wound treatments. One resident frequently waited a week or more for a shower, while another had to wait extended periods for incontinence care. Additionally, a resident experienced a 14-day delay in surgical staple removal due to communication errors and low staffing. The Regional Director of Clinical Services acknowledged the staffing ratio was unacceptable and not in line with facility standards.
Failure to Report Abuse and Inaccurate Elopement Investigation
Penalty
Summary
The facility failed to report an allegation of potential sexual abuse involving two residents. A Certified Nursing Assistant (CNA) observed one resident with their pants down and another resident standing beside the bed. The CNA reported the incident to the floor nurse and the Regional Director of Clinical Services, but no documentation was made in the residents' medical records. The Licensed Practical Nurse (LPN) involved did not document the incident, citing a busy schedule as the reason. The Regional Director of Clinical Services instructed the CNA to notify the abuse coordinator but did not follow up on the incident. The Nursing Home Administrator confirmed that the incident should have been reported to the State Agency. The facility also failed to provide an accurate investigation regarding the elopement of two residents. The Facility Reported Incident (FRI) inaccurately described the event, stating that the residents were found on the facility sidewalk when they were actually found in the roadway. The door alarm was silenced by a CNA without checking for residents, and the residents were outside for seven minutes before being accompanied back inside. The Regional Director of Operations admitted to not accurately reporting the incident and only reviewed the video footage after submitting the initial report. The facility's policies on incident reporting and abuse prevention were not followed. The policy requires incidents to be documented within 24 hours, including all pertinent information, and for allegations of abuse to be reported to the Administrator and state agency within specified timeframes. The failure to document and report the incidents as required by the facility's policies resulted in a lack of investigation and potential for continued abuse and elopement.
Failure to Investigate Allegation of Potential Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential sexual abuse between two residents, identified as Resident #4 and Resident #5. Resident #4, who has severe cognitive impairment due to Alzheimer's Disease, was found standing beside Resident #5's bed, who has intact cognition. A Certified Nursing Assistant (CNA) observed Resident #5 with his pants down and genitalia exposed, and a washcloth nearby, suggesting possible peri-care. The CNA reported the incident to the floor nurse, LPN A, and the Regional Director of Clinical Services G, but no documentation of the event was found in the residents' electronic medical records. LPN A acknowledged being informed of the incident but did not document it, citing a busy workload with around 29 residents to care for. The Regional Director of Clinical Services G confirmed receiving a call about the incident and instructed the CNA to notify the abuse coordinator but did not follow up further. The Nursing Home Administrator stated that all allegations of abuse should be reported immediately and investigated, which was not done in this case. The facility's policy requires documentation of incidents within 24 hours, including all pertinent information, which was not adhered to in this situation.
Delayed Meal Service Frustrates Residents
Penalty
Summary
The facility failed to provide meals at regular times in accordance with resident preferences and expectations, affecting five residents out of eight reviewed for timely meal delivery. On multiple occasions, residents experienced significant delays in receiving their meals, leading to frustration and hunger. For instance, one resident, who preferred to eat in his room, received his lunch at 1:15 PM, despite the meal service starting at noon. Another resident expressed frustration while waiting for lunch, and the lunch cart for his hall was not delivered until 1:10 PM. These delays were consistent across different halls, with the main dining room being served first, followed by a rotation of the other halls. The Registered Dietitian (RD) confirmed that the main dining room is always served first, and the other halls are rotated, but there was no formal policy in place, only a posted schedule. On another day, residents in the main dining room were observed waiting for lunch without any beverage service or activities, with the first hall cart delivered at 12:48 PM and the last tray served at 1:31 PM. The facility's posted meal schedule indicated that room trays should follow the dining room service, but the actual delivery times were significantly delayed, causing dissatisfaction among residents.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The facility failed to implement its policy regarding the timely administration of medications and physician notification when medications were unavailable, affecting two residents. For one resident with a history of urinary tract infections, the ordered antibiotic Nitrofurantoin was not administered as scheduled due to unavailability. The medication was supposed to start on the evening of June 18, 2024, but was not given until the evening of June 19, 2024. Despite the nurse contacting the pharmacy, the physician was not notified of the delay, which was against the facility's policy. Another resident, diagnosed with enterocolitis due to clostridium difficile, experienced a similar issue. The ordered antibiotic Vancomycin was not administered at the scheduled times on June 26, 2024, because it had not been delivered by the pharmacy. The first dose was only given the following morning. Again, there was no documentation indicating that the physician had been informed of the delay. The facility's policy required immediate action and physician notification when medications were unavailable, which was not followed in these cases.
Inadequate Supervision Leading to Resident Fall and Injury
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility to provide adequate supervision to prevent a fall with injury for Resident R3. R3, admitted with diagnoses including dementia, depression, history of falling, hearing loss, insomnia, and weakness, required various levels of assistance for daily activities due to severe cognitive impairment. Despite being identified as a high fall risk and having a documented history of falls, R3 experienced multiple falls within a short period after admission, culminating in a fall resulting in a significant head injury and subsequent hospitalization for a subdural hematoma. The report highlights instances where staff members were not present or available to provide necessary supervision and assistance to R3. For example, during the fall incident on 3/26/24, the Licensed Practical Nurse (LPN) assumed R3 had slipped in his urine and fell, indicating a lack of direct supervision at the time of the fall. Additionally, witness statements from Certified Nurse Aides (CNAs) revealed gaps in monitoring R3, with one CNA noting that the aide assigned to R3 was on lunch break when the incident occurred. The facility's policies related to fall prevention and admission criteria were reviewed in the context of the deficiency. The policy on Fall Prevention Program emphasized the importance of assessing residents for fall risk and updating care plans accordingly, indicating a potential gap in the implementation of these protocols for R3.
Infection Control Deficiencies in PPE Usage and TB Testing
Penalty
Summary
The facility failed to properly don personal protective equipment (PPE) for three residents who were placed in Enhanced Barrier Precaution (EBP) rooms. Observations revealed that staff did not wear gowns or shields when providing direct care to these residents, despite clear instructions on the doors and physician orders indicating the need for enhanced barrier precautions. Interviews with staff and residents confirmed that PPE was not consistently used, and some staff were unaware of the EBP requirements or the location of PPE supplies. This deficiency was observed in multiple instances, including direct care activities such as assisting residents with mobility and catheter care, where staff did not wear the required PPE. Additionally, the facility failed to maintain an effective infection control program for tuberculosis (TB) testing, prevention, and management. Several residents did not receive the required TB tests upon admission, and there were discrepancies in the documentation of TB testing and results. For instance, one resident's medication administration record indicated a PPD reading without any test being administered. The Director of Nursing (DON) acknowledged that TB testing should be done on admission and that there were lapses in adding and completing the necessary orders. The facility's policy required TB screening and testing for new admissions, but this was not consistently followed. The report highlights significant lapses in the facility's infection control practices, both in the use of PPE for residents under EBP and in the TB testing protocol for new admissions. These deficiencies were identified through observations, interviews, and record reviews, indicating a need for improved staff education and adherence to infection control policies. The facility's failure to implement these measures properly poses a risk of infection transmission among residents and staff.
Failure to Obtain Physician Order for Indwelling Catheter
Penalty
Summary
The facility failed to obtain a physician order for an indwelling catheter for a resident (R3) who had returned from the hospital with the device. Observations revealed that R3 had an indwelling catheter without a corresponding physician order, and staff were unaware of the necessity for such an order. The resident's progress notes indicated multiple instances where the catheter was replaced due to the resident removing it, yet no physician order was documented for the catheter's use. The care plan mentioned the need for an indwelling catheter, but this was not supported by a physician's order as required by facility policy. On multiple occasions, staff observed issues with the catheter, including blood-tinged urine and the catheter falling out during care. Despite these observations, there was no documented physician order for the catheter. Interviews with staff, including a CNA, RN Educator, and the Director of Nursing, confirmed that a physician's order is required for the use of an indwelling catheter, but none was found in R3's records. The facility's policy mandates that urinary catheterization must be performed in accordance with physician orders, which was not adhered to in this case.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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